This blog is originally appeared at The Texas Tribune.

It took 20 hours and three visits to the ER before doctors finally admitted the 18-year-old, pregnant and critically ill, to the hospital as her condition continued to deteriorate. She is one of at least two women who have died as a result of Texas’ abortion ban.

By Lizzie Presser and Kavitha Surana, ProPublica
Nov. 1, 2024
4 AM Central
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Candace Fails desperately screamed for help at the Texas hospital, pleading with staff to assist her pregnant daughter. “Do something,” she cried out on the morning of October 29, 2023.

Nevaeh Crain, 18, was wracked with pain, too weak to stand, and blood was soaking her thighs. The day of her baby shower, she had been feverish and vomiting. Within 12 hours, she had been to two different emergency rooms, only to return home each time feeling worse.

At the first hospital, doctors diagnosed her with strep throat, neglecting to investigate her intense abdominal cramps. At the second, medical records show, she tested positive for sepsis — a life-threatening infection. But despite this, doctors dismissed her condition, pointing to the baby’s heartbeat and telling Crain she was stable enough to leave.

On her third visit to the hospital, an obstetrician ordered two ultrasounds to “confirm fetal demise,” as a nurse noted, before transferring her to intensive care.

By the time Crain arrived at the hospital, more than two hours had passed, and her blood pressure had dropped dangerously. A nurse noted that her lips had turned “blue and dusky.” Her organs began to fail.

Hours later, she was dead.

Fails, who would have seen her daughter turn 20 this Friday, still cannot comprehend why Crain’s life-threatening emergency wasn’t treated as an urgent crisis.

But this is the grim reality many pregnant women now face in states with strict abortion bans, as doctors and lawyers have explained to ProPublica.

“Pregnant women have become essentially untouchables,” said Sara Rosenbaum, a health law and policy professor emerita at George Washington University.

Texas’s abortion ban imposes severe penalties, including prison time, for any intervention that ends a fetal heartbeat, regardless of whether the pregnancy is wanted. While the law allows exceptions for life-threatening conditions, doctors told ProPublica that widespread confusion and fear of legal repercussions are changing how they approach complicated cases.

In states with strict abortion bans, patients with pregnancy complications are sometimes shuffled between hospitals like “hot potatoes,” with healthcare providers hesitant to offer care that could attract legal scrutiny, doctors explained. In some instances, medical teams spend critical time debating legalities and documenting their decisions, preparing for the possibility of having to defend their actions in court.

Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, pointed out the anxiety patients face in these situations: “Am I being sent home because I really am OK? Or am I being sent home because they’re afraid that the solution to what’s going on with my pregnancy would be ending the pregnancy, and they’re not allowed to do that?”

A federal law exists to prevent emergency room doctors from withholding lifesaving care.

Passed nearly four decades ago, this law mandates that emergency rooms must stabilize patients in medical crises. The Biden administration argues that this requirement extends to situations where an abortion might be necessary to save the patient’s life.

No state has fought this interpretation more vigorously than Texas. The state has warned doctors that its abortion ban takes precedence over the administration’s guidance on federal law, threatening up to 99 years in prison for those who violate it.

In response, ProPublica condensed more than 800 pages of Crain’s medical records into a four-page timeline, consulting two maternal-fetal medicine specialists in the process. The timeline was then reviewed by nine doctors, including researchers from prestigious universities, OB-GYNs with expertise in managing miscarriages, and specialists in emergency medicine and maternal health.

Some of the doctors consulted said the first ER missed critical warning signs of infection that should have been addressed. All agreed that the doctor at the second hospital made a grave error in sending Crain home when her symptoms of sepsis had not improved. And when Crain returned for the third visit, every expert agreed there was no medical justification for delaying action—such as waiting for two ultrasounds—before taking decisive steps to save her life.

“This is how these restrictions kill women,” said Dr. Dara Kass, a former regional director at the Department of Health and Human Services and an emergency room physician in New York. “It is never just one decision, it’s never just one doctor, it’s never just one nurse.”

While the doctors were cautious in saying whether Crain’s death could have been definitively prevented, they agreed that earlier admission for monitoring and continuous treatment could have increased the chances of saving both Crain and her fetus.

There was a possibility that Crain could have remained pregnant with medical intervention, they said. If an early delivery had been required, the hospital was fully capable of caring for a baby born at the edge of viability. In another scenario, if the infection had progressed too far, ending the pregnancy might have been necessary to save Crain’s life.

Doctors involved in Crain’s care did not respond to several requests for comment. The two hospitals—Baptist Hospitals of Southeast Texas and Christus Southeast Texas St. Elizabeth—declined to answer detailed questions about her treatment.

Fails and Crain both believed abortion was morally wrong. The teenager could only support it in cases of rape or life-threatening illness, a sentiment she often shared with her mother. They didn’t focus on the legality of abortion; for them, it was about how their Christian faith guided their personal choices.

When they learned Crain was pregnant with a girl, the two of them dreamed together about the little dresses they could buy and what kind of mother Crain would become. Crain chose the name Lillian, and Fails was eager to meet her granddaughter.

But when her daughter became seriously ill, Fails expected doctors to do everything in their power to prevent a potentially fatal emergency, even if it meant losing Lillian. In her view, however, the medical team seemed more focused on monitoring the fetal heartbeat than on treating Crain’s deteriorating health.

“I know it sounds selfish, and God knows I would rather have both of them, but if I had to choose,” Fails said, her voice breaking, “I would have chosen my daughter.”

“I’m in a lot of pain”
Crain had just graduated from high school in her hometown of Vidor, Texas, in May of 2023, when she discovered she was pregnant.

She and her boyfriend of two years, Randall Broussard, were inseparable—always side by side, whether they were playfully wrestling over vapes or snuggling on the couch, watching vampire movies. Crain was drawn to his gentle nature, while he admired how easily she made friends and how quickly she could make people laugh. Though they were young, they’d already talked about starting a family. Broussard, who had eight siblings, dreamed of having a large family; Crain, on the other hand, envisioned having a daughter and the kind of close relationship she shared with her own mother. Earlier that year, Broussard had given Crain a small diamond ring — “a promise,” he said, “that I will always love you.”

On the morning of their baby shower, October 28, 2023, Crain woke with a headache. Her mom had decorated the house with pink balloons, and Crain had laid out Halloween-themed platters for the guests. But soon, nausea set in. Crain started vomiting and developed a fever. As the guests arrived, Broussard opened gifts—onesies, diapers, and bows—while Crain kept closing her eyes, unable to stay awake.

Around 3 p.m., her family insisted that Crain needed to go to the hospital.

Broussard drove her to Baptist Hospitals of Southeast Texas, where they sat in the waiting room for four hours. When Crain began vomiting, the staff gave her a plastic pan. When she wasn’t retching, she rested her head in her boyfriend’s lap.

A nurse practitioner ordered a test for strep throat, which came back positive, according to medical records. However, physicians told ProPublica that in a pregnant patient, abdominal pain and vomiting should not have been quickly attributed to strep; a doctor should have also evaluated her pregnancy.

Instead, Baptist Hospitals discharged Crain with a prescription for antibiotics. She was home by 9 p.m. and soon fell asleep, but within hours, she woke her mother. “Mom, my stomach is still hurting,” she said in the dark bedroom at 3 a.m. “I’m in a lot of pain.”

Fails drove Broussard and Crain to another hospital in town, Christus Southeast Texas St. Elizabeth. Around 4:20 a.m., OB-GYN William Hawkins observed that Crain had a temperature of 102.8°F and an abnormally high pulse, according to medical records. A nurse noted that Crain rated her abdominal pain as a seven out of 10.

Her vital signs suggested the possibility of sepsis, records show. Medical experts told ProPublica that it’s standard practice to immediately treat patients showing signs of sepsis, a potentially life-threatening condition that can escalate rapidly. These patients should be monitored closely until their vital signs stabilize, and tests and scans are done to identify the source of the infection. If the infection was in Crain’s uterus, the fetus would likely need to be removed via surgery.

In a room at the obstetric emergency department, a nurse wrapped a sensor belt around Crain’s belly to check the fetal heart rate. “Baby’s fine,” Broussard told Fails, who was sitting in the hallway.

Despite receiving two hours of IV fluids, one dose of antibiotics, and some Tylenol, Crain’s fever remained high, her pulse stayed elevated, and the fetal heart rate was abnormally fast, according to medical records. Hawkins noted that Crain had strep and a urinary tract infection, wrote a prescription, and discharged her.

Hawkins had a history of missing infections. Eight years earlier, the Texas Medical Board found that he had failed to diagnose appendicitis in one patient and syphilis in another. In the latter case, the board noted that his error “may have contributed to the fetal demise of one of her twins.” As a result, the board ordered that Hawkins’ medical practice be monitored, though the order was lifted two years later. (Hawkins did not respond to multiple attempts to contact him.)

All of the doctors who reviewed Crain’s vital signs for ProPublica agreed that she should have been admitted. “She should have never left, never left,” said Elise Boos, an OB-GYN in Tennessee.

Kass, the New York emergency physician, put it in starker terms: When they discharged her, they were “pushing her down the path of no return.”

“It’s bullshit,” Fails said, watching as Broussard rolled Crain out in a wheelchair, unable to walk on her own. Fails had expected the hospital to keep her overnight. Her daughter was breathing heavily, hunched over in pain, pale in the face. Normally talkative, the teen was eerily quiet.

Back home, around 7 a.m., Fails tried to make her daughter as comfortable as possible as she cried and moaned in pain. Crain told her mother she needed to pee, and Fails helped her into the bathroom. “Mom, come here,” Crain called from the toilet. Blood stained her underwear.

The blood confirmed Fails’ worst fear: This was a miscarriage.

At 9 a.m., a full day after the nausea began, they were back at Christus St. Elizabeth. Crain’s lips were drained of color, and she kept saying she was going to pass out. Staff began administering IV antibiotics and performed a bedside ultrasound.

Around 9:30 a.m., Dr. Marcelo Totorica, the OB on duty, couldn’t find a fetal heartbeat, according to records. He told the family he was sorry for their loss.

Standard protocol when a critically ill patient experiences a miscarriage is to stabilize her and, in most cases, rush her to the operating room for delivery, medical experts told ProPublica. This is especially critical when there is a spreading infection. But at Christus St. Elizabeth, the OB-GYN continued only antibiotic treatment. A half-hour later, as nurses placed a catheter, Fails noticed her daughter’s thighs were covered in blood.

At 10 a.m., Melissa McIntosh, a labor and delivery nurse, spoke with Dr. Totorica about Crain’s deteriorating condition. The teen was now having contractions. “Dr. Totorica states to not move patient,” McIntosh wrote after their conversation. “Dr. Totorica states there is a slight chance patient may need to go to ICU and he wants the bedside ultrasound to be done stat for sure before admitting to room.”

Although an ultrasound had already been performed, Totorica requested a second one.

The first ultrasound hadn’t preserved an image of Crain’s womb in the medical record. “Bedside ultrasounds aren’t always set up to save images permanently,” explained Dr. Abbott, the Boston OB-GYN.

Under Texas’ abortion laws, doctors are required to document the absence of a fetal heartbeat before performing any procedure that could end a pregnancy. Exceptions for medical emergencies mandate that physicians carefully document their reasoning. “Pretty consistently, people say, ‘Until we can be absolutely certain this isn’t a normal pregnancy, we can’t do anything, because it could be alleged that we were doing an abortion,’” said Dr. Tony Ogburn, an OB-GYN in San Antonio.

By 10:40 a.m., Crain’s blood pressure was dropping. Minutes later, Totorica called for an emergency team over the loudspeakers.

Around 11 a.m., two hours after Crain had arrived at the hospital, a second ultrasound was performed. A nurse wrote: “Bedside ultrasound at this time to confirm fetal demise per Dr. Totorica’s orders.”

When doctors wheeled Crain into the ICU at 11:20 a.m., Fails stayed by her side, rubbing her head as her daughter drifted in and out of consciousness. Crain was unable to sign consent forms due to “extreme pain,” according to the records, so Fails signed a release for “unplanned dilation and curettage” or “unplanned cesarean section.”

But the doctors quickly determined that it was now too risky to operate. They suspected Crain had developed disseminated intravascular coagulation, a dangerous complication of sepsis that causes internal bleeding.

Frantic and crying, Fails locked eyes with her daughter. “You’re strong, Nevaeh,” she said, her voice shaking. “God made us strong.”

Crain sat up in the cot. Old, black blood poured from her nostrils and mouth.

“The Law Is on Our Side”
Crain is one of at least two pregnant Texas women who died after doctors delayed treating miscarriages, ProPublica found.

Texas Attorney General Ken Paxton has succeeded in making his state the only one in the country that isn’t required to follow the Biden administration’s efforts to ensure that emergency departments don’t turn away patients like Crain.

After the U.S. Supreme Court overturned the constitutional right to abortion, the Biden administration issued guidance on how states with abortion bans should adhere to the Emergency Medical Treatment and Labor Act (EMTALA). This federal law requires hospitals receiving Medicare funds — which includes virtually all hospitals — to stabilize or transfer anyone who arrives in their emergency rooms, including pregnant patients, even if that means providing an abortion in life-threatening cases.

Paxton responded by filing a lawsuit in 2022, arguing that the federal guidance “forces hospitals and doctors to commit crimes” and was an “attempt to use federal law to transform every emergency room in the country into a walk-in abortion clinic.”

A central part of the legal battle has been the definition of who qualifies for an abortion. The federal EMTALA guidelines apply when the health of the pregnant patient is in “serious jeopardy,” a broader standard than the Texas abortion law, which only allows exceptions for a “risk of death” or a “serious risk of substantial impairment of a major bodily function.”

The lawsuit moved through three layers of federal courts, each time with rulings from judges appointed by former President Donald Trump, whose court appointments played a key role in overturning Roe v. Wade.

After U.S. District Judge James Wesley Hendrix, a Trump appointee, quickly sided with Texas, Paxton celebrated the decision as a victory over “left-wing bureaucrats in Washington.”

“The decision last night proves what we knew all along,” Paxton said. “The law is on our side.”

In 2024, the U.S. Court of Appeals for the 5th Circuit upheld the order in a ruling written by Judge Kurt D. Engelhardt, another Trump appointee.

The Biden administration appealed to the U.S. Supreme Court, urging the justices to clarify that some emergency abortions are permitted. Yet, even amid reports of preventable deaths tied to abortion bans, the Supreme Court declined to intervene last month.

Paxton hailed the ruling as “a major victory” for Texas’ abortion ban.

He has also made it clear that he will pursue charges against physicians who perform abortions, unless they can prove the cases fall within the narrow exceptions outlined by state law.

In 2023, Paxton sent a letter threatening to prosecute a doctor who had received court approval to perform an emergency abortion for a Dallas woman. Paxton insisted that the doctor and the patient hadn’t proven that the patient’s condition posed a life-threatening risk.

Many doctors say this kind of messaging has led to a widespread reluctance to treat pregnant patients with complications.

Since the abortion bans took effect, an OB-GYN at a major hospital in San Antonio reported seeing an increase in pregnant patients being transferred from hospitals across Southern Texas for complications that could have been treated locally. This well-resourced hospital is perceived as having more institutional support to handle abortion and miscarriage management. “Other providers are transferring those patients to our centers because, frankly, they don’t want to deal with them,” the doctor said.

After Crain died, Fails couldn’t stop thinking about how Christus Southeast Hospital had ignored her daughter’s condition. “She was bleeding,” Fails said. “Why didn’t they do anything to help it along instead of waiting for another ultrasound to confirm the baby is dead?”

In the end, it was the medical examiner, not the doctors at the hospital, who removed Lillian from Crain’s womb. His autopsy didn’t answer Fails’ lingering questions about what the hospitals missed and why. He classified the death as “natural” and attributed it to “complications of pregnancy.” However, he did note that Crain had been “repeatedly seeking medical care for a progressive illness” just before she died.

In November 2023, Fails reached out to medical malpractice lawyers to explore seeking justice through the courts. But a new legal barrier stood in her way.

If Crain had experienced the same delays while being an inpatient, Fails would have only needed to prove that the hospital had violated medical standards. That, she believed, would have been relatively easy to do. But because the delays and discharges occurred in the hospital’s emergency room, lawyers told her that Texas law set a much higher burden of proof: “willful and wanton negligence.”

No lawyer has agreed to take the case.

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